The Faces of Anxiety and Bravery: Four Hours in the UNC Psychiatric Emergency Department
Carley Arendas spent four hours in the pyschiatric unit of the UNC Medical Center Emergency Department. In this paper, she examines the routines and strategies of the doctors, nurses, and social workers who make it their life’s work to help patients in need of psychiatric care.
CHAPEL HILL, N.C.—A lively town, most famously known as the home of The University of North Carolina at Chapel Hill. Several blocks from campus, however, stand several large buildings, some connected, creating a small community. The clean, crisp air, radiant sunshine, and winding sidewalks lead to the UNC Medical Center. Aiding more than 65,000 individuals each year, one building includes the Emergency Department that cares for a wide range of cases in the local or national area.
These are the occurrences in just four hours of a typical day:
The Emergency Department: organized but hectic as nurses acquire supplies for their patients; doctors consult ill individuals; a young boy complains to a station nurse that his mother urgently needs water. The numerous halls that lead to different sections of the hospital are filled with patients, doctors, and nurses. The psychiatric doctor on call remains at his station: a room once called the out-patient care unit, but now being renovated for psychiatric doctors and patients. His shift includes consulting 25 patients with a range of illnesses and ages. Most of his patients stay in the psychiatric unit of the Emergency Department for hours or several days, but 4 or 5 of his patients stay in the hospital for more than a month. Some patients suffer from anxiety or depression while others are diagnosed with more serious mental illnesses like schizophrenia. The psychiatric floor employs nurses, psychiatrists, and practitioners; it provides patients with urgent care, but they are either discharged shortly after, kept for a certain amount of time, or admitted into the psychiatric ward of the hospital. The third floor of the ward treats general psychiatric cases; the fourth floor treats geriatric and crisis patients; the fifth floor treats adolescents. The doctor explains that the most common reason individuals are admitted is because they are “homeless and depressed, but do not necessarily have a place to live.”
The social worker stationed next to the psychiatrist exits the former out-patient care center, walks down a hallway, and starts down the stairs. The exit of the stairwell opens to more blank-walled hallways with blue-tiled floors which then lead to the main Emergency Department. A large, open room surrounded by curtains that block off spaces for admitted patients is packed with nurses, doctors, and patients; vital machines, supply drawers, and gurneys fill the area. The social worker passes the nurses station while making small talk with a nurse on-call and opens a curtain. Sitting on a bed is a 51-year-old African American male who was admitted into the ED last night by police for alcohol abuse. The patient felt suicidal when he was brought in, but now he munches on chips with a tray of food in his lap. The social worker initiates conversation when she asks how the man is feeling. Wearing a hospital gown and yellow socks, the patient looks to the social worker and responds with a muffled voice, “I’m tired.” The social worker looks at the man with a questioning expression, but he continues to eat his chips. A nurse walks in greeting the patient and takes his vitals.
The Ground Neuroscience Hospital (GNSH) consists of another large, open room with curtains that divide the space into individual areas for each patient. The difference between the GNSH and the Emergency Department, however, is the GNSH’s secured nurses station. Glass windows and two locked doors surround the area and separate the patients from the nurses; video monitors that display the main hallway and each room hang on a wall; two windows with three small holes allow nurses to speak with patients if they need assistance or to make a call. The other, less secure station with a sliding glass window was recently removed because a patient jumped through and stabbed a nurse in the neck with a pencil. Each nurse checks in on patients to take vitals, administer medication, or give them food. One room connected to the station isolates a 10-year-old Asian female with severe autism from the other patients.
The psychiatrist on-call walks into the GNSH wearing a white coat, collared shirt, and tie. I follow behind the doctor while he walks to the far door of the station, swipes his key card, and enters the patient’s area. Greeting a 22-year-old Caucasian male with schizophrenia, the doctor and I sit down and begin to speak with the patient. Admitted for consuming 10-15 pills of Seroquel, an antipsychotic typically taken by patients with schizophrenia, the patient lays on a bed wearing purple scrubs. While I glance at the patient, the dim light of the room slightly reveals the man’s numerous tattoos. After a few simple questions to spark a deeper conversation, the patient begins to speak about his two children; his 9-year-old son and 12-year-old daughter live in Connecticut. His eyes light up when he discusses the play his daughter stars in, but he quickly looks down with sadness and explains that he hasn’t seen his children in over one month.
Nurses inside the station discuss who brought the 22-year-old into the hospital last night. One nurse reads from the patient’s chart that his girlfriend voluntarily took him, but each nurse agree that the patient never consumed the pills that he claimed to. “There’s no way he took those pills. He might have threatened to, but that high of a dosage of Seroquel? He would’ve been asleep all day. Trust me, he wasn’t asleep”, a nurse responds.
One male nurse lays back in his rolling chair and eats a taco salad; another nurse gets juice for the autistic patient; one patient makes a phone call. The sounds of clicking keyboards, a television, and the voice of the young girl speaking through the glass to a nurse surround the GNSH. Meanwhile, several nurses recall stories from while working in the Psychiatric Emergency Department. “This is the black eye I got when a patient became aggressive”, one nurse explains while showing a picture of the wound. Others write reports or look up patient records. The patients remain in the dark, windowless area; some watch TV; others await their time of discharge. The darkness of the rooms helps some patients rest, but many only recognize the time of day by the rolling of the food cart that signals meal times.
A male nurse walks into the room of the 10-year-old female who suffers from severe autism. The young girl smiles and laughs while the nurse greets her. A locked door separates her from the other patients due to a previous incident that caused nurses to place her there. When previously placed in the open arrangements of the GNSH, the nurses found her attacking other individuals who were trying to use the bathroom facilities. “How are you today” the nurse asks. The girl replies with a joyful smile and urges the nurse to play “Miss Mary Mack” with her; she begins to exchange hand claps. As the game goes on, she starts to hit the male nurse harder and harder on the hands. “You need to be gentle” the nurse says with assertiveness while the girl begins to breathe heavy. “Good decision?”, the girl asks and points to the bathroom in her room with a thumbs-up. The nurse replies, “That’s right, and what’s a bad decision?” The girl points to the door that leads to other patients.
The male nurse leaves the room and the girl remains at the transparent window. “What’s your name?” she asks. The nurse replies, “You know my name. What’s my name?” The girl repeats the nurse’s name over and over.
Back at the temporary center for the Emergency Department’s psychiatric staff, a Psychiatric Mental Health Nurse Practitioner (PMHNP) prepares to consult a recently-admitted-patient. When admitted, the 40-year-old Caucasian female told the nurses in the Emergency Department that she was having anxious thoughts and “did not feel like moving forward with her life.” The nurse practitioner checks the patient’s medication history; she takes 3 mg of Benzodiazepine Klonopin that is used to treat panic disorder and anxiety. The practitioner shows another nurse the woman’s chart because this particular prescribed dosage of Benzodiazepine Klonopin is very high; the other nurse stares with concern. A right and two lefts down hallways with white walls and colorful pictures lead the PMHNP to the GNSH; she instinctively swipes her key card to open the door to the nurse’s station.
While she greets the on-call individuals, she briefly explains the patient she’s seeing, swipes her access card again, and enters the patient’s area. As she slides back a squeaky curtain, a 40-year-old woman sits on the hospital bed. With bags under her eyes, she greets the nurse practitioner with excitement. The nurse apologizes for the awaited consult and proceeds to ask the patient about her current state. The patient’s emotion shifts from joyful to anxious. Fighting back tears, she explains that her husband recently just left her, so she decided to stop taking her medication to show him that she doesn’t need to depend on it to “make it through the day.” The nurse thanks the patient for being strong and brave, but with a soothing voice, she explains that the patient’s failure to take the medication could create serious withdrawal symptoms.
Two patients spring from their beds and rush over to the windows of the nurse’s station. “Help! Help!” they plea. “He fell!” The nurses rush to the fallen patient; the nurse practitioner leaves her consult to help. An older African American male lies on the cold floor of the psychiatric Emergency Department. “Don’t worry. I’ll get up now. I’m okay” the patient exclaims. With guidance, the man reaches the bed again, but he falls over with another thud. The patient regains his balance and nurses take his vitals; the 40-year-old woman waits in her room.
The nurse practitioner walks back to the patient she was consulting and begins her session again. Explaining withdrawal symptoms, the anxious woman understands that she must start taking her medication again. The nurse practitioner nods with assurance and explains that certain events an individual experienced in their past such as sexual assault or abandonment can cause extreme feelings of stress and a sense of feeling overwhelmed when similar situations arise. The practitioner encourages the patient to set aside the opinions of her husband and, instead, focus on her mental health; the patient nods in agreement. “I need to focus on me, and him not showing up here today shows me something” the patient says.
While the practitioner suggests a checklist, the woman interrupts, and tells the nurse that she needs to be released from the Emergency Department tonight to help her mother who suffers from Muscular Dystrophy. In a soothing voice, the nurse explains that she understands, but she must finish her consult. The practitioner follows the consult with brief questions: “What day is it? Who is the President? What news stories have you watched recently?” Individuals under severe anxiety cannot correctly answer those simple questions, but the patient answers each one correctly. The doctor tells the patient she will make arrangements for the patient to be discharged in 45 minutes while other patients lay sleeping in their rooms. A new team of nurses clock in and a typical night in the GNSH begins.
Wolf, A. (2015, 9 July). UNC Emergency Department in Chapel Hill [Online Image]. Retrieved on November 2, 2015 from http://news.unchealthcare.org/news/2015/july/hillsborough-campus-opens